HomeMy WebLinkAboutSWG2022-00620 - SWG Application - 1/8/2024 f 1l c cal( W t1 k -nA..c,
415 N 6Tu STREET,SHELTON WA 98584
MASON COUNTY SHELTON: 360-427-9670,EXT.400
COMMUNITY SERVICES BELFAIR:360-2754467, EXT.400
ELMA:360-482-5269,EXT.400
'0&n%,P6miny Ena me kAN gRCan iq Health FAX: $60427-7798
HOMEOWNER OS`S INSTALLATION REQUEST ,/
Name of Applicant/Owner: &0 Jt"_i�v<'✓`�1,,11� Date: 't
Mailing Address of Applicant: PO 117"t
�E��• r State: QA Zip:
City: S�II �S
Phone Number: 36,0 (o�� ' ISO '� Email: , t o,; '— 6e-v% QCp IAn
12-digit Parcel Number:
Approved Septic Permit Number: SWG 20a2 -00(0.�o (seepage I ofdesignform)
Septic Design Expiration Date: kD —(seepage 2 of design form)
Septic Designer or Engineer: 0`01) , SFT (see page ! of design form)
Designer/Engineer must stamp their approval for honteowner installation.
Owner Agreement: ' DesigneltEh9lneer Stamp: '
I am the primary owner of this non-shoreline residential property and I '
this will be my primary residence. t have rend and understand the
attached "Mason County Homeowner OSS/nthdiation I formation".
t agree to foltow the Mason County procedure,that(allure standards, mid
applicable regulations during this installation with the understanding '
was
to plain a"render my design/permit void or xnusable, avo tcrt
I FNSkIIOEegNEe
LAPIi1a0 1L Iel
Signature of Applicant/Owner
HEALTH DEPARTMENT USE ONLY
Request Review: ?Approved ❑ Denied
r/ INSPECTION DA�T7E�SJ:��
Neme 0f ER S cialist: Pre-install Meeting: 1 =-2
Signature: /t{'��, Date: o/F oeptn lmpeceon. .
COmmeob: ry rS,t�^GI'_',� l - Final Inspection:
yt/AA,,K
This form may a scanned and available for Publkviawonthe Mason County Website. SW Updated 9/12/2017